Nursing

I-SBAR

I – Introduce Yourself

Your Name:

D#:

Your Title:

Reason for being there:

S – Situation

Patient:

Attending Physician:

Age:

Patient Chief Complaint/Primary Medical Diagnosis and Clinical Significance:

Gender/Identity:

Height/Weight:

Allergies:

Code Status:

Advance Directive (durable power of attorney, living will, other) and Clinical Significance:

Pathophysiology of Primary Medical Diagnosis:

Privacy Code:

Date of Care/Time:

B – Background

Include clinical significance with each:

Past Medical History:

Past Surgical History:

Immunizations Received:

Social History/Socioeconomic Factors:

A – Assessment

Vital Signs:

B/P

HR

RR

TEMP

SP02

PAIN

Fall Risk:

Accu-check:

IV Site:

IV Fluids:

Lab/Test Results:

I and O

Isolation

Isolation Precautions: Y ☐ N ☐

Contact Air ☐ Droplet ☐

RESPIRATORY

CARDIOVASCULAR

NEUROLOGICAL

GI/GU

INTEGUMENTARY

PSYCHOLOGICAL FAMILY – SUPPORT

SAFETY

Teaching needed:

Quality in Safety Education Nurses (QSEN) Risk(s) Identified:

R – REQUEST/ RECOMMENDATION

Hand off report to:

From:

Initial Assessment Findings & Time

Vital signs:

T:

P:

Resp:

Sp02:

BP:

Height:

Weight:

Apical HR:

Intake:

Output:

Pain scale used with rationale:

O (Onset): Did your pain start suddenly or gradually get worse?

P (Palliative, Provocative) What makes the pain better/worse?

Q (Quality) How is the pain described?

R (Radiation) Does the pain travel or spread anywhere else? If so, where?

S (Severity) What is the intensity of the pain?

T (Temporal) Is the pain constant or does it come and go?

Head and neck (inspect and palpate scalp, hair and skull, facial expression/symmetry, trachea):

Respiratory (lung sounds, breathing effort, accessory muscles):

Cardiovascular (jugular vein, carotid arteries, cardiac sounds, cardiac rhythm):

Abdomen (inspection, bowel sounds, palpation, contour):

Bowel incontinence:

Bowel plan:

Last BM:

Neurological (mental status, cranial nerves, sensory, motor, deep tendon reflexes, pupils):

Musculoskeletal (ROM, dorsalis pedis and post-tibial pulses, muscle strength of upper and lower extremities):

Genitourinary (burning with urination, frequency, color of urine):

Urinary incontinence:

Toileting plan:

Pelvic (female: LMP):

Rectal (bleeding, hemorrhoids):

Integumentary (rashes, lesions, wounds, etc.):

Specialty assessment (mental health exam, fetal heart rate, etc.):

Abuse screen (physical, elderly, child, sexual, etc.):

IV access (type/size, site, reason for IV access, type of fluid/rate, reason for type of IV fluid, assessment of IV site, last dressing change):

Psychological/Psychosocial/Family Support/Religious/ Cultural Dynamics:

Growth and Development: (Developmental stage according to Erikson and your assessment findings):

Ongoing Assessment Findings & Time

Vital signs:

T:

P:

Resp:

Sp02:

BP:

Height:

Weight:

Apical HR:

Intake:

Output:

Pain scale used with rationale:

O (Onset): Did your pain start suddenly or gradually get worse?

P (Palliative, Provocative) What makes the pain better/worse?

Q (Quality) How is the pain described?

R (Radiation) Does the pain travel or spread anywhere else? If so, where?

S (Severity) What is the intensity of the pain?

T (Temporal) Is the pain constant or does it come and go?

Head and neck (inspect and palpate scalp, hair and skull, facial expression/symmetry, trachea):

Respiratory (lung sounds, breathing effort, accessory muscles):

Cardiovascular (jugular vein, carotid arteries, cardiac sounds, cardiac rhythm):

Abdomen (inspection, bowel sounds, palpation, contour):

Bowel incontinence:

Bowel plan:

Last BM:

Neurological (mental status, cranial nerves, sensory, motor, deep tendon reflexes, pupils):

Musculoskeletal (ROM, dorsalis pedis and post-tibial pulses, muscle strength of upper and lower extremities):

Genitourinary (burning with urination, frequency, color of urine):

Urinary incontinence:

Toileting plan:

Pelvic (female: LMP):

Rectal (bleeding, hemorrhoids):

Integumentary (rashes, lesions, wounds, etc.):

Specialty assessment (mental health exam, fetal heart rate, etc.):

Abuse screen (physical, elderly, child, sexual, etc.):

IV access (type/size, site, reason for IV access, type of fluid/rate, reason for type of IV fluid, assessment of IV site, last dressing change):

Psychological/Psychosocial/Family Support/Religious/ Cultural Dynamics:

Growth and Development: (Developmental stage according to Erikson and your assessment findings):

Date/Time

Nursing Note

Telemetry Rhythm Strip

If applicable: Attach your patient’s rhythm strip below and determine the following information:

PRI:

QRS:

QT:

Rate:

Rhythm:

Test

Result/ Date

Norm

Reason out of norm/reason for drawing if normal or N/A if not drawn

WBC

RBC

Hgb

Hct

Plt

Chol

Trig

LDH

PT

APTT

AST

ALT

Tdl*

Test

Result/ Date

Norm

Reason out of norm/reason for drawing if normal or N/A if not drawn

Glu

BUN

Na

K

Cl

Creat

CO2

Ca

Phos

Mag

T. Pro

Alb

Tdl*

Items

Order/ Frequency

Prioritization (Prioritize the healthcare provider prescriptions (orders) based on your assessment cues)

Reason (Explain specifically why ordered for this patient, potential complications, anticipated interventions and teaching required)

Diet

I/O

VS

Activity

Accu-check

Foley

NG tube

PEG tube

PEJ tube

Chest tube

Trach

Suctioning

Drains

Ostomy

Dressing change and/or wound care

Treatments

Restraints

Safety devices

Special equipment

Other

Recognize Cues – Identify relevant and important information from different sources (e.g., medical history, vital signs).

List the data/cues that are relevant and are interpreted as clinically significant.

Significant

Significant

Significant

Significant

Significant

Data/Cue 1

Data/Cue 2

Data/Cue 3

Data/Cue 4

Data/Cue 5

Analyze Cues – Organizing and linking the recognized cues to the patient’s clinical presentation.

Interpret the relevant clinical data/cues.

Identify the top three most likely problems.

Is additional data needed to confirm the clinical significance of the cues at this point? Be specific; what additional data is needed to confirm?

Potential Problem 1

Potential Problem 2

Potential Problem 3

Additional Data

Additional Data

Additional Data

Prioritize Hypothesis – Evaluating and ranking hypotheses according to priority (urgency, likelihood, risk, difficulty, time, etc.).

Of the potential problems you identified, which problem(s) is most likely present? Which problem is the most concerning and why?

Generate Solutions – Identifying expected outcomes and using hypotheses to define a set of interventions for the expected outcomes.

Based on the most urgent problem, what are the priority actions/interventions? For each priority action, what are the desired outcomes?

Priority Action/Intervention 1

Priority Action/Intervention 2

Priority Action/Intervention 3

Expected Outcomes

Expected Outcomes

Expected Outcomes

Are there any interventions or actions that should be avoided? Include rationale.

Take Action – Implementing the solution(s) that addresses the highest priorities.

How should the interventions or actions above be accomplished? (Performed, administered, requested, communicated, taught, documented, etc.).

List environmental and/or individual factors impacting the ability of the nurse to generate solutions and take action.

Environmental Factor 1

Individual Factor 1

Environmental Factor 2

Individual Factor 2

Environmental Factor 3

Individual Factor 3

Evaluate Outcomes – Comparing observed outcomes against expected outcomes.

Compare observed outcomes to expected outcomes – has the patient’s status improved, declined or remain unchanged?

Does the observed outcome match expected outcome? If not, what are the additional actions/interventions that should be considered?

Observed Outcomes

Observed Outcomes

Observed Outcomes

Matches Expected Outcome?

Matches Expected Outcome?

Matches Expected Outcome?

If the patient status has not improved, what other issues may be present?

List environmental and/or individual factors impacting the achievement of outcomes.

Environmental Factor 1

Individual Factor 1

Environmental Factor 2

Individual Factor 2

Environmental Factor 3

Individual Factor 3

Priority (Top 3) Interventions, Rationales and Education to Perform for Nursing Diagnosis

Priority (Top 3) Information/Findings/ Signs and Symptoms (Cues)

Priority (Top 3) Lab Values/Diagnostic Results Related to Nursing Diagnosis

Potential and Actual Complications (Include dietary risk factors)

Nursing Diagnosis

Priority (Top 3) Contributing Social Determinants of Health (SDOH)/ Healthcare Disparities Factors

Priority (Top 3) Patient Outcomes and Actions to evaluate the Outcomes

Priority (Top 3) Medication(s) and Patient Teaching r/t Diagnosis. (Include medication side effects and nursing interventions for each)

Identify how the Four Spheres of Care (AACN, 2019) were addressed while caring for your patient. If a sphere is not applicable, provide rationale and/or exploration of how this could be incorporated into care. 1. Wellness, Disease Prevention (includes physical and mental health needs). 2. Chronic Disease Management (includes managing chronic disease and preventing further complications). 3. Regenerative/Restorative Care (includes complex acute, trauma and critical care and acute exacerbations of chronic conditions). 4. Hospice/Palliative Care (includes end of live care and supportive care for complex diseases and/or rehabilitative care).

Priority (Top 3) Discharge Instructions and Evaluation of Effectiveness of Teaching (Include resources to mitigate SDOH and healthcare disparities. Include teach/back and/or verbalized understanding)

Med Name

Med Classification

Rationale for Med

Home, Current,

or New Med

Time Due

Contraindications/ Interactions

Nursing Complications, Interventions & Considerations

Patient Education